Periop Med Flashcards
PERIOP MED (Psych/drugs) - Methamphetamines
[20B11] Discuss the perioperative implications for a patient known to use methamphetamine.
Mimic - endogenous monoamines (sympathomimetic) –> excitation and euphoria
- CVS
- Sympathomimetic - Resp
- smoking +/- PHTN - Metabolic
- Hyperthermia
- Met acidosis
- rhabdo
- malnutition
Acute vs chronic use
Chronic
- withdrawal, dependence, comorbidities
Hx
- drug / duration
- comorbidities
Ex
- intox
Ix
- viral
- ECG - long QT
consent? aggression –> BZD?
INTRAOP
1. BP - labile -
2. Aim euvolaemia
Postop
- monitor withdrawal - sleep/eat/depress
- psych / A&D
MAKE UP
[-] Discuss the perioperative implications for a patient known to use CANNABIS (instead of methamphetamine.)
SAD - substance abused disorder
CNS-depressant
- EtOH
- BZD
- opioids
CNS-stim
- cocaine
- amphetamines
- ecstasy
- CBD
Aim
1. Prevent w/d effective analgesia
2. Sx Rx of affective/behavioural problems
Key
1. Acute (consent) vs chronic use (poor nutrition, comorbid)
2. Difficult IV access
3. PPE
4. Post op analgesia plan
Natural vs synthetic
Oral vs pulm
Low bioavail
Long t1/2
Low tox
CBD
PM10 2019: Medicinal cannabis for chronic pain
OHA p.337
PERIOP MED (Neuro) – Parkinson’s disease
[21A06] You will be anaesthetising a 63-year-old man with severe Parkinson’s disease who is booked for an inguinal hernia repair. Discuss the issues that are relevant to providing perioperative care for this patient. (also 15A10, 09A05)
RTB
rigidity/tremor/bradykinesia
AUTONOMIC/cog/emo
Pathophys
ACh (exc) and DA (inh) imbal in BG –> loss of DA–> unopp EXC –> tremor/rigid
Drugs
- Levodopa
- Carbidopa
- DA agonist
- MAO-Bi
- COMTi
- Anti-ACH
- NMDA antag
Features
1. Cog change
2. Autonomic instability
3. Aspiration risk
4. Meds
- continue Da drugs
- avoid anti-Da )
Post op - return to meds
PERIOP MED (Neuro) – Myasthenia gravis
[20B09] A patient with myasthenia gravis presents for emergency laparotomy for small bowel obstruction.
Discuss your perioperative management of this patient including your choice of anaesthesia. (also 14B09, 06A05, 03B03)
MG
IgG autoab + POST-syn nAChR at NMJ
PERIOP MED (Neuro) – Peri-operative stroke
[19B13] List the risk factors for perioperative stroke. (50%)
Discuss the measures you use to ̄ perioperative stroke in high-risk patients undergoing major orthopaedic surgery. (50%) (also 12A13)
RF
patient:
1. Age > 70yo
2. F
3. Comorbin
Intraop
1. Type (cardiac/CEA)
2. Urgency (emerg > elec)
3. GA>RA>LA
4. Duration
Post op
1. AMI/AF
2. Dehyd
3. Hypergly
Periop Mx to dec stroke
1. Pre op
-
PERIOP MED (Neuro) – Traumatic SC transection at C6 (acute)
[15A14] A 40-year-old requires a laparotomy ten days after an isolated traumatic spinal cord transection at C6.
1. Outline the key anaesthetic issues. (50%)
2. How would these influence your anaesthetic management? (50%)
Key
1. Unstable C-spine
2. Neurogenic shock
3. Acute laparotomy
Neurogenic
- loss ANS
- dec BP, dec HR, peri VD
PERIOP MED (Neuro) – Longstanding C5-6 quadriplegia
[13B15] A 25-year-old female with longstanding C5-6 quadriplegia requires ureteric stent insertion. Outline the implications for anaesthesia.
PERIOP MED (Neuro) - Epilepsy
[13A05] What are the perioperative concerns for the anaesthetist managing a patient with epilepsy?
Epilepsy - common 1%
Anti-epileptic
Anaes agent ~ seizures
- IV - avoid etom/ket
- VA - avoind enf
- Opioid - avoid peth/tram
- NMBA - avoid sux(K up)/laudanosine from atrac
- LA - re ceiling dose
CYP450
Carb/pheny - indu
Valp - inhibit
PERIOP MED (GI) – Liver
[10B03] A 45-year-old man with a longstanding history of alcoholism is booked for upper gastrointestinal endoscopy and banding of oesophageal varices following an episode of haematemesis.
(a) How is the severity of this patient’s liver disease assessed? (50%)
(b) How do these findings influence your evaluation of this patient’s perioperative risk? (50%)
Liver scoring
1. MELD
- BIC - bili/INR/Cr
2. CP
- A/B/P/E/C
Extra-hepatic sequelae
1. HRS
2. HPS
Type/urgency of procedure
Type of anaes require
Comorbid
PERIOP MED (Haem) – von Willebrand disease
[19A13] Outline your approach to the perioperative management of a patient who gives a strong family history of von Willebrand disease.
Types of vWD (ISTH)
Quant def: 1 and 3
Qual def: 2
Mx Responder vs non-responder
Rx - DDAVP (desmo)
*rel vWF
Mx options
Mx - diff types of vWD
Features
1. 2050 a.a. plasma glyco
2. 1% AD chr 12mut
3. mucosal bleed
Rx:
1+2a - DDAVP
2b+3 - vWF replacement
Cryo - IIIF(fibronectin, fibrinogen, vWF), FVIII, FXIII
*F8/vWF = Humate P
PERIOP MED (Haem) – Anaemia 1
[19A10] These are the blood results of a 65-year-old man scheduled for a revision total hip replacement.
- Interpret these results (30%)
- How would you manage this patient preoperatively? (70%)
DDx
Micro/Normo/Macro
1. Hb
2. MCV - M/N/M
- IDA
- Ferritin <30
- Non-IDA
- Ferritin > 100
Optimise
PERIOP MED (Haem) – Minimising blood loss and transfusion
[15B03] An adult patient is scheduled for a major operation during which significant blood loss is expected. Describe strategies you would consider perioperatively when planning to minimise blood loss and transfusion requirement.
Key strategies PBM
*1. Mx anaemia
*2. Min BL
*3. Imp tol to anaemia
PERIOP MED (Haem) - VTE
[15A12] In PAC, you are assessing a patient who is concerned about the risk of developing venous thromboembolism (VTE) perioperatively.
a) Outline the patient factors that increase the risk of VTE. (50%)
b) Describe measures that may reduce the risk of perioperative VTE (50%)
(83.4%) Candidates were expected to at least mention
- a) Previous history/family, obesity, cancer and oestrogen containing pills
- b) Measures would include minimising the preop, intraop and postoperative risks
Background
(also 08B05, 05A02)
RF = virchows triad
Stasis, hypercoag, endo dam
Mx
1. Preop
a. STRATIFY
- Intraop
a. GCS
b. IPC
c. Pharm - Postop
a. Mob early
PERIOP MED – Addison’s disease
[21B08] Discuss how a diagnosis of Addison’s disease would influence your perioperative management of a patient who requires an urgent laparotomy for bowel obstruction.
Addison dx
- hypoTension
- low cortisol (GC) and aldosterone (MC)
Effect (add crisis from stress)
1. BGL low
2. Na low
3. K High
4. Urea high
Mx
1. Fludrocort
2. Hydrocort (GC+MC)
Preop
- C - consult endocrine
Intraop
1. IAL for BP monitoring
2. Electrolytes - Na/K
3. Steroid cover
- Hydrocortisone
- Dex 6-8mg - good for 24h
x dex - no MC activity
Post op
1.
PERIOP MED (Endocrine) – T2DM
[19A03] a) List the causes of increased perioperative morbidity and mortality in surgical patients with type 2 diabetes mellitus. (30%)
b) Outline the principles of perioperative management of these patients. (70%)..
(also 17A05, 09B02, 06A03)
Key
1. HbA1c <8.5% (postop if > 9)
2. BSL perio op: 5-10mmol/L
Perio
Meds
1. OHA - WH DOS
2. SGLT-2 - WH 2/7 prior + DOS
- If Ket > 1 and pH < 7.3/ HCO3 < 15 –> ivf + ins/dex
PERIOP MED (Autoimmune, congenital, acquired) – Myotonic dystrophy
[16A02] A 30-year-old patient with myotonic dystrophy is scheduled for surgery for acute appendicitis.
a) Outline the important factors in the preoperative assessment of this patient. (50%)
b) Describe how this patient’s myotonic dystrophy will affect your anaesthetic management. (50%)
RESP ISSUES
*RLD + OSA
Myotonia = prolonged muscle contraction
Dystrophy = muscle wasting
Dystonia = atrophy + contraction
DM (1 - chr 19; 2 - chr 3) and MC
Muscle dystrophy = progressive weakness
INHERITENCE
Main = x linked = DMD and Becker
CF
Systems
1. AW/Resp = bulbar, RLD
2. CVS = CM , MCP
3. GI = delayed motility –> ASPIR
Anaes
1. Sux - X - K+ myo contracture
2. Sens to CNS depress
3. Neo - X - Myo cont
PERIOP MED (Psych/drugs) – Cease smoking
[16A11] As a perioperative physician, what strategies can you offer to assist a patient to cease smoking tobacco and how will you best communicate them? (also 09B14)
2 parts to the Q
(79%) Borderline standard: To achieve a pass candidates needed to describe a reasonable non- pharmacological intervention that is effective in the medium to long term AND have a grasp of at least one suitable replacement therapy.
- Non-pharm intervention Med/long term
a. Indiv counselling
b. GBT
c. rapid smoking aversive therapy - Replacement therapy
NRT - patch/gum/strips - Pharm
NrPA - varenicline
Bupropion
Nortriptyline
Clonidine
Communicate
AAR - ask/advice/refer
Benefits
PG12(POM) Perioperative smoking 2014
Smoking Cessation Benefits
Whic PG?
1 day = low COHb
3 weeks = improve skin healing
6mo = imm fx
PG12(POM) Perioperative smoking 2014
